CASE MANAGER
Listed on 2026-01-19
-
Nursing
Clinical Nurse Specialist, Nurse Practitioner, RN Nurse
If you are an existing employee of South Shore Health then please apply through the internal career site.
Requisition Number: R-21652
Facility: LOC
0001 – 55 Fogg Road, 55 Fogg Road Weymouth, MA 02190
Department Name: SSH Care Progression
Status: Full time
Budgeted
Hours:
40
Shift: Day (United States of America)
Under the general supervision of the Case Management Manager acts as a patient advocate/Case Manager to SSH&EC clients. An autonomous role that coordinates, negotiates, procures services and resources for, and manages the care of complex patients to facilitate achievement of quality and cost efficient patient outcomes. Looks for opportunities to reduce cost while assuring the highest quality of care is maintained.
Applies review criteria to determine medical necessity for admission and continued stay. Provides clinically-based case management, discharge planning and care coordination to facilitate the delivery of cost-effective quality healthcare and assists in the identification of appropriate utilization of resources across the continuum of care. Works collaboratively with interdisciplinary staff internal and external to the Organization. Participates in quality improvement and evaluation processes related to the management of patient care.
The Case Manager is on‑site and available seven (7) days a week as well as holidays and, therefore, is required to work a weekend rotation and also an occasional holiday.
- Using Interqual Criteria, physician certification, and payor specific criteria, assists the physician in determining the medical necessity for observation, admission and continued stays.
- Identifies cases daily that fail to meet criteria and refers these cases to appropriate manager or physician advisor for secondary review.
- Contacts attending physicians daily on cases that lack adequate documentation warranting acute hospitalization and clarifies for them the necessary clinical documentation required to help support medical necessity.
- Contacts the attending physician to notify him/her of decision to issue notice of non‑coverage, explains UR process and insurance coverage requirements, obtains physician written concurrence when necessary (e.g., Medicare patients), informs the patient and/or next of kin when insurance coverage must be terminated for the current admission, and issues the termination letter for the Medicare patient.
- Reinstates insurance coverage when patient condition becomes acute and meets criteria again, issuing a reinstatement letter.
- Continues review of all patients using criteria and determines need for continued hospitalization based upon third‑party payor/insurance guidelines.
- Provides clinical data/information to contracted third‑party payers while patient is hospitalized to ensure continued reimbursement and to avoid reimbursement delays within 24 hours of request.
- Identifies and reviews observation patients to determine the correct patient level of care daily prior to 12 PM.
- Consults with physicians, nursing, admitting, and outside insurance case managers to determine the appropriate status of patient. Refers the questionable status to internal physician advisor or EHR according to the departmental process.
- Assumes the role of review coordinator for observation services; reviews medical record for appropriateness of status and level of care, and facilitates the correct level of care, utilizing Inter Qual for Observation.
- Works with physicians, nursing and staff, patients and families to arrange prompt and safe discharge.
- Takes telephone orders from physicians changing patient status from observation to inpatient admission when monitoring observation status, calling or paging the physician if an inpatient admission is required sooner than the 24‑hour benchmark.
- Identifies potential transition planning problems in a timely manner to set up services required.
- Works with attending physician to move patient through the SSH&EC system and set up appropriate services or referrals (e.g., SNF/VNA/Home Pharmacy).
- I…
(If this job is in fact in your jurisdiction, then you may be using a Proxy or VPN to access this site, and to progress further, you should change your connectivity to another mobile device or PC).